Form DD 3067-11 DD 3067-11 Science, Mathematics, and Research for Transformation (S

Science, Mathematics, and Research for Transformation (SMART) Scholarship
Service Agreement Amendment Request

OMB NO. 0704-0466
OMB approval expires
YYYYMMDD

PRIVACY ACT STATEMENT
AUTHORITY: 10 U.S.C. 4093, Science, Mathematics, and Research for Transformation (SMART) Defense Education Program; 10 U.S.C. 133a, Under
Secretary of Defense for Research and Engineering; DoD Directive 5137.02, Under Secretary of Defense for Research and Engineering (USD(R&E)); DoD
Instruction 1025.09, Science, Mathematics, and Research for Transformation Defense Education Program.
PURPOSE: To record an amendment to a SMART Scholar’s SMART Scholarship Service Agreement.
ROUTINE USES: While the information requested on this form is primarily intended to be used internally, in certain circumstances it may be necessary to
disclose this information externally, pursuant to 5 U.S.C. 552a(b)(3), including: to contractors, grantees, experts, consultants, students, and others performing or
working on a contract, service, grant, cooperative agreement, or other assignment for the Federal Government when necessary to accomplish an agency
function; and to consumer reporting agencies as defined in the Fair Credit Reporting Act (15 U.S.C. 1681a(f)) or the Federal Claims Collection Act of 1966 (31
U.S.C. 3701(a)(3)) to aid in the collection of outstanding debts owed to the Federal government, typically to provide an incentive for debtors to repay delinquent
Federal government debts by making these debts part of their credit records. A complete list of routine uses may be found in the applicable Privacy Act System
of Records Notice, DUSDA 14, Science, Mathematics, and Research for Transformation (SMART) Information management System, found at
https://dpcld.defense.gov/Portals/49/Documents/Privacy/SORNs/OSDJS/DUSDA-14.pdf?ver=KO2ZkLWhxB3QCZoRTElMFA%3d%3d
DISCLOSURE: Voluntary; however, failure to provide the requested information may result in SMART Scholar being non-compliant with SMART policy, and
subject to possible dismissal.
The public reporting burden for this collection of information is estimated to average one hour per response, including the time for reviewing instructions,
searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments
regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing the burden, to the Department of Defense,
Washington Headquarters Services, at [email protected]. Respondents should be aware that notwithstanding any
other provisions of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB
control number.
INSTRUCTION: SMART Scholarship Program Scholars requesting to amend an existing SMART Service Agreement must submit this request. The request is
reviewed and will be considered for approval by the SMART Scholarship Program and/or appropriate sponsoring Department of Defense (DoD) Component
office. Changes approved pursuant to this Service Agreement Amendment Request (SAAR) modify only the specific terms of the SMART Service Agreement
amended. The remainder of the SMART Service Agreement remains in full force and effect.

SECTION 1 – SMART SCHOLAR AWARD INFORMATION
Cohort Year:

Name (Last, First, Middle Initial):
Phone:
AWARD TYPE (X one):

NEEDS DD67
Email:

Recruitment

Retention

a. SPONSORING COMPONENT

d. DEGREE (X one)

b. SPONSORING FACILITY

BS

BS/MS

Degree Completion Date (YYYYMMDD):*

MS

c. LOCATION (City/State)

PhD

Degree Conferral Date (YYYYMMDD):**

Notes: *Degree Completion Date: Date on which an individual completes all degree requirements. This generally occurs prior to degree conferral and is not set
forth on official transcripts.
** Degree Conferral Date: Date on which a degree is bestowed upon an individual. This is set forth on the official transcript reflecting the degree earned
and may occur after degree completion.

SECTION 2 – TYPE OF AMENDMENT (X one) See following pages for instructions and required documentation.
Academic Institution

Additional Enrollment

Additional Tuition

Award Length Decrease

Award Length Increase

Award Type

Degree Level

Field of Study

Full Time Enrollment

Internship Waiver

Leave of Absence

Sponsoring Facility

Stipend Rate Increase

Withdrawal

Alternatively Timed
Internship

Other (describe)

SECTION 3 – REQUEST DETAILS (Required for all types of amendment requests)
Please provide a brief summary of the request.

If requesting an award length increase, an award length decrease, or a leave of absence, provide revised degree completion and conferral dates.
Revised Degree Completion Date (YYYYMMDD):*

Revised Degree Conferral Date (YYYYMMDD):**

Notes: *Degree Completion Date: Date on which an individual completes all degree requirements. This generally occurs prior to degree conferral and is not set
forth on official transcripts.
** Degree Conferral Date: Date on which a degree is bestowed upon an individual. This is set forth on the official transcript reflecting the degree earned
and may occur after degree completion.

DD FORM 3067-11, 20220701 DRAFT

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SECTION 4 – COMPLIANCE (initial next to each)
I understand that if I don’t provide the other required documentation specific to this type of amendment, detailed in the “Required Documentation”
column of the matrix on page 3 my SAAR will be considered incomplete and may not reviewed.
I understand that SAARs are reviewed and will be considered for approval by the SMART Scholarship Program and/or the appropriate sponsoring
DoD Component office.
I understand that if this SAAR is approved, changes modify only the specific terms of the SMART Service Agreement amended by the SAAR. The
remainder of the SMART Service Agreement and any previously approved amendments remain in full force and effect.
I understand that if this SAAR is denied, I must comply with the SMART Service Agreement and any previously approved amendments.
I understand that, if this SAAR is denied and I default on any term or condition of my SMART Service Agreement, I may be dismissed from the
SMART Scholarship Program and subject to the terms in Section 2 of the SMART Service Agreement.

SECTION 5 - CERTIFICATION BY SMART SCHOLARSHIP PROGRAM SCHOLAR
In signing my SMART Service Agreement Amendment (SAAR), I certify that all information is true and accurate to the best of my knowledge. I have attached/
completed additional requests and/or supporting documentation, as applicable. I understand that approval of my SAAR is determined on a case-by-case basis
and at the discretion of the SMART Scholarship Program. I certify that I understand that any approved award length increase incurs an additional commensurate
service commitment. I certify that I have read and understand the conditions, terms, and requirements of this Service Agreement Amendment and that I will
comply with them.
b. SIGNATURE
a. NAME (Last, First, Middle Initial)
c. DATE SIGNED (YYYYMMDD)

-------------------- DO NOT WRITE BELOW THIS LINE / SMART SCHOLARSHIP PROGRAM USE ONLY -------------------SECTION 6 – SMART PROGRAM REVIEW

NEEDS DD67

SMART Scholar ID number:

Sponsoring Facility (SF) Verification:
Is there a change in award cost
associated with this request?
Reviewed by (Name):

N/A

N/A

Attached

Yes: Increase in cost

SF supports

Yes: Decrease in cost

SF does not support
Amount:

Date processed: (YYYYMMDD)

SECTION 7 – SMART PROGRAM DECISION
Request Approved

Funding Approved

NAME (Last, First, Middle Initial)

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Funding Denied

Request Denied

SIGNATURE

Acknowledged (FOR WITHDRAWAL ONLY)
DATE SIGNED (YYYYMMDD)

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Instruction to the SMART Scholar: Instructions for requests to amend the SMART Service Agreement (SSA) are detailed in the chart below. The SAAR is
incomplete without the required documentation.

Amendment Request

Applies to

Required Documentation

1. Signed personal statement detailing the
circumstances of the request, including confirmation
SMART Scholars who request to change their
that all other aspects of the award will not change;
awarded Academic Institution or whose SF requests
2.0 Documentation that the new academic institution
them to change their academic institution.
accepts the scholar into the program; and
3. Revised Degree Completion Plan.

Academic Institution

1. Year-round enrollment and/or completion of
coursework required by degree
program/academic institution.
2. Required coursework during summer or winter
terms without tuition.
3. Elective coursework during summer or winter
terms without tuition.

1. If the coursework and/or enrollment is required for
degree completion, and cannot be taken another
time, provide a letter on official university letterhead
from the scholar’s research advisor, academic
advisor, or appropriate dean of the academic
institution confirming the need;
2. If the course can be taken during the Fall/Spring
term, provide written statement explaining the
extenuating circumstances for this request; and
3. Documentation verifying there is no SMART
Scholarship Program funding associated with this
request.

1. Year-round enrollment and/or completion of
coursework required by degree
program/academic institution.
2. Required coursework during summer or winter
terms.
3. Elective coursework during summer or winter
terms.

1. If the coursework and/or enrollment is required for
degree completion, and cannot be taken another
time, provide a letter on official university letterhead
from the scholar’s research advisor, academic
advisor, or appropriate dean of the academic
institution confirming the need;
2. If the course can be taken during the Fall/Spring
term, provide signed personal statement explaining
the extenuating circumstances for this request; and
3. Documentation of the SMART Scholarship
Program funding associated with this request.

Award Length Decrease

SMART Scholars who request to decrease their
award length are recommended to do so one term
prior to the proposed degree completion date.

1. Letter on official letterhead from a research
advisor, academic advisor, or appropriate dean of
the scholar’s academic institution:
a. Confirming the new date when the scholar will
have completed all educational requirements for the
scholar’s degree.
b. Confirmation of a new degree conferral date;
2. Signed personal statement detailing the
circumstances causing the decrease in degree
completion and confirmation that you have
discussed the need for the change with the SF; and
3. Revised Degree Completion Plan.

Award Length Increase

1. Letter on official letterhead from a research
advisor, academic advisor, or appropriate dean of
the scholar’s academic institution confirming:
a. The extenuating circumstance that caused the
delay in degree completion including dates and
steps taken to mitigate risks;
SMART Scholars whose degree completion is
b. Steps remaining prior to degree completion and
delayed due to circumstances outside of their
when those milestones will be met; and confirmation
control, and who have not exhausted the five-year
that the scholar is capable of completing the degree
funding cap are eligible to submit a request for an
in accordance with the proposed award length
award length increase.
change.
2. Signed personal statement detailing:
If the delay in degree completion is scholar driven, a
a. Extenuating circumstances causing the delay in
Leave of Absence SAAR must be submitted in lieu
degree completion, including revised degree
of an award length increase request.
completion and conferral dates; dates;
b. Steps taken to mitigate risks and/or manage
Award length increase requests must be submitted
the issue(s) causing the delay;
one term prior to original degree completion date.
c. Steps remaining prior to degree completion;
d. Confirmation that the scholar has discussed
the need for the change with the SF;
e. Whether non-SMART Scholarship Program
funding sources are assisting in funding the
remainder of the degree; and
3. Revised Degree Completion Plan.

Additional Enrollment

Additional Tuition

NEEDS DD67

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Amendment Request

Award Type

Degree Level

Field of Study

Applies to

Required Documentation

SMART Scholars who are directed to change their
SMART Scholarship Program award type from
Recruitment to Retention or Retention to
Recruitment.

1. Signed personal statement detailing the
circumstances of the request, including confirmation
that all other aspects of the award will not change;
2. Statement of support from sponsoring facility,
confirming the need for the change; and
3. If changing from recruitment to retention,
documentation reflecting that the Scholar’s SF
confirms that they have the capacity and business
processes in place to accept a MIPR and disburse
SMART funds to the SMART Scholar Scholarship
Program , and understands the processes
associated with a retention scholar.

SMART Scholars requesting to change their degree
level from a BS to a MS or joint BS/MS program or
to change from a PhD to a MS.

1. Signed personal statement detailing the
circumstances of the request, including:
a. The details of the request and how it aligns to
the SF mission;
b. Confirmation that the details of the request
have been discussed with the scholar’s SF
supervisor and/or mentor; and
c. Confirmation that all other aspects of the award
will not change.
2. Statement of support from the SF, confirming the
need for the change.
3. Statement of support from the academic
institution, verifying acceptance into the degree
program and/or the academic institution’s ability to
grant the degree being requested.

SMART Scholars requesting to change their field of
study within the SMART-Scholarship Program
approved disciplines.

1. Signed personal statement detailing the
circumstances of the request, including confirmation
that all other aspects of the award will not change;
and
2. Statement of support from the SF, confirming the
need for the change.

SMART Scholars who must drop below full-time
enrollment status, due to circumstances outside of
their control, and are requesting to waive the fulltime status policy for one academic term.

1. Signed personal statement detailing the
circumstances of the request, including confirmation
that all other aspects of the award will not change
and confirmation that the request only applies to one
term; and
2. Confirmation, on official letterhead, from the
academic advisor detailing the need to drop below
full-time enrollment status and confirming that
dropping below full-time enrollment will not
negatively impact the SMART Scholar’s ability to
complete their degree, per the terms of their SMART
Service Agreement.

NEEDS DD67

Full Time Enrollment

Internship

Internship Waiver Request:
SMART Scholars requesting to waive an internship.
Requests for a waiver are considered for a single
internship period at a time. A waiver of an internship
does not reduce the length of a SMART scholar’s
service commitment.
Alternatively Timed Internship:
SMART Scholars requesting an alternatively timed
internship. Requests for alternatively timed
internships are considered for a single internship
period at a time.

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1. Signed personal statement detailing the
circumstances of the request, including confirmation
that all other aspects of the award will not change;
and
2. Statement of support from the SF, confirming the
internship is approved to be waived or alternatively
timed.

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Amendment Request

Applies to

Required Documentation

SMART Scholars requesting LOAs that require an
absence from school for:
1. Personal or family medical circumstances, as
defined by the Family and Medical Leave Act.
2. Military activation

1. Signed personal statement, detailing the need for
the request and commitment to continuing to submit
the Annual Report each June for the duration of the
LOA; and
2. Letter on official letterhead from a research
advisor, academic advisor, or appropriate dean of
the scholar’s academic institution confirming:
a. Approval of requested LOA and that the
academic institution will allow the scholar to re-enroll
after the LOA is complete (if applicable); and
b. The scholar’s degree completion and conferral
dates.

SMART Scholars requesting LOAs that do not
require an absence from school:
1. Award length change denial (if directed)
2. SMART Scholar has exceeded the maximum
award length permitted by the SMART Program
for their degree level

1. Signed personal statement, detailing the need for
the request and commitment to:
a. Submitting transcripts at the close of each term;
and
b. Continue submitting the Annual Report each
June for the duration of the LOA.
2. Letter on official letterhead from a research
advisor, academic advisor, or appropriate dean of
the scholar’s academic institution confirming:
a. Extenuating circumstance that caused the
delay in degree completion including dates and
steps taken to mitigate risks;
b. Steps remaining prior to degree completion and
when those milestones will be met; and
c. That the scholar is capable of completing the
degree in accordance with the proposed award
length change.
3. Revised Degree Completion Plan.
4. (For retention scholars only) Statement of support
from SF supervisor, to include:
a. Approach to balancing academic commitments
with employment;
b. If and how the SMART scholar’s academic
work is related to their employment;
c. Whether the SF is represented on the SMART
scholar’s academic committee, if applicable
(PhDs only); and
d. What arrangements have been made to ensure
timely completion of the SMART-Scholarship
Program funded degree.

Sponsoring Facility

SMART Scholars who lose sponsorship of their SF
for reasons that would not warrant a dismissal from
the SMART Scholarship Program and SMART
scholars whose SF recommends a change of SF.

Signed personal statement detailing the
circumstances of the request, including confirmation
that all other aspects of the award will not change.

Stipend Rate Increase

SMART Scholars who are requesting a stipend rate
increase after having a SMART Scholarship
Program-funded degree conferred, while in pursuit
of an advanced degree also funded by the SMART
Scholarship Program.

Submit documentation from the SMART scholar’s
academic institution confirming the conferral of the
STEM degree funded by SMART Scholarship
Program.

Withdrawal

SMART Scholars who wish to withdraw from the
SMART Scholarship Program.

SMART Scholars may provide documentation
supporting the reason(s) for their withdrawal, if they
choose; however, no additional documentation is
required.

SMART Scholars that have general requests not
specifically outlined above.

1. Signed personal statement detailing the
circumstances of the request, including confirmation
that all other aspects of the award will not change;
and
2. Any applicable documentation supporting the
request.

Leave of Absence (LOA)

NEEDS DD67

Other

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